Tick, Tick, Tick
The history of medicine is millennia long. It has been characterized by genuine curiosity, it has sometimes been misguided or wrong, it has included gradual, and wonderful, development and understanding, and even those considered qualified to manage it have been increasingly highly regulated. That is not to say that there has not been a snake oil industry, charlatans, and a focus on money — there most certainly has — but the general trend is toward improvement, better understanding, and better results. Unfortunately, that has been much more true in other countries than it has in this one.
The history of psychiatry has been much harder to track and characterize, in part because of very long stretches of time when the concept of (separately understood and diagnosable) psychiatric conditions was either not understood or not accepted. And because a significant proportion of what we would call psychiatric problems has been subjective, or subject to varying interpretation, then the confident recognition and understanding of psychiatric problems has been slower, and sometimes less confident, to rely on.
It is loosely fair to say that the history of psychiatry, at least in this country, is about 200-250 years old. Benjamin Rush is a marker. And concepts of psychiatric diagnoses and treatments have been very unsteady, and unreliable anyway.
Even today, in what we might like to tell ourselves are enlightened and advanced times, concepts of psychiatric diagnosis, and especially treatment, are not clear, and not agreed. There are several reasons for this stalling and misdirection, not least of which are things like the common human wish for something new (whether or not it’s true or real), and the incessant effort on the parts of various actors to get other people’s money. And in medicine, and psychiatry, that is effected by making a diagnosis (whether or not it’s true, or real), and “treating” it.
We tried — we really did try — to make all of this objective, but much of the effort really never worked well. If, for example, we felt we had reason to think that clinical depression was caused by underactivity of dopamine, norepinephrine, or serotonin, we could never, in any given patient, find out which neurotransmitter was underactive. That would in theory have led us to identify, based on what we knew, or felt we knew, about which antidepressants increased the activity of which neurotransmitter, which antidepressant would be the “right” one for which patient. And we’re talking about urine tests, blood tests, and even spinal fluid tests. When we have relied on monoamine oxidase inhibitors (MAOI), which increase all three of the neurotransmitters the underactivity of which we told ourselves was the cause of clinical depression, those don’t work much of the time, either. (I prescribe MAOI more than anyone else I have known, and I’m very familiar with them, but I never expect unquestioned success. They do work better than any other antidepressant medications, but not nearly 100%.) And the same, in a way, is true of antipsychotics. Some are very closely chemically related to others. But of pairs like that, one might work very well, and at low dose, and a closely chemically related one might not work at all, even at high dose. For clinical depression, the thing that works better than anything, and still not nearly 100%, is electroshock treatment, and no one has any idea how that works.
In my opinion, the high water mark for psychiatry has been psychotherapy. And that’s been uneven, too. There are several or many “schools” of psychotherapy, and some of them have essentially no theoretical basis. I feel Freud came closest to excellent value, not because each of his particular theories or conflicts was shown to be correct, but because he more clearly introduced a concept of the unconscious, and because he focused on the impact of childhood, or the “formative years,” on continued development. These contributions are sustaining and overarching, and I have found them to be of central value.
The problem with psychotherapy is that it can take time, and it requires hard work and dedication, on the parts of the patient and the therapist. In the sense that what “forms” in the “formative years” is “formed,” no one simply becomes someone he or she is not, because of insights developed in psychotherapy. But there are some gains to make. The patient can come to understand, in a conscious way, what was unconscious (but still exerting a powerful influence), and the patient then has the option to work on making some changes. When I was in training in psychiatry, it occurred to me that the value of psychotherapy for what we call personality disorders was that the patient could learn to see him- or herself coming. One of my professors (they’re called “attendings”) coincidentally put it in a different way. He said psychoanalysis (that’s what he did) for personality disorder smoothed some of the rougher edges. For problems that are not personality disorders, the results are much more prominent, and easier to arrive at.
So, back to the theme of this communication. I am a psychiatrist, and I’ve been one for over 48 years. Psychiatrists in training, or the younger ones, these days, do not learn psychotherapy. It’s too hard, and neither the training programs nor the trainees want to bother. Writing prescriptions is much easier, and it’s more likely to satisfy everyone, even if the prescription doesn’t work, or is based on the wrong diagnosis. So, when the old-timers, like me, are gone, there won’t be any good mental health treatment. There will still be loads of wrong prescriptions for wrong diagnoses, and even some brief and aimless conversations. But I hear about it all the time, even now: mental health treaters who don’t exert themselves, and don’t accomplish anything, because they don’t know how, and can’t be bothered, and they’re watching the cash register.
